Provider Demographics
NPI:1053831248
Name:CLEMMENSEN, EMMALYNN PEPPER (MS, LPCC, CRC)
Entity Type:Individual
Prefix:
First Name:EMMALYNN
Middle Name:PEPPER
Last Name:CLEMMENSEN
Suffix:
Gender:F
Credentials:MS, LPCC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2321
Mailing Address - Country:US
Mailing Address - Phone:763-682-4400
Mailing Address - Fax:
Practice Address - Street 1:308 12TH AVE S
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-2321
Practice Address - Country:US
Practice Address - Phone:763-682-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01534101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health